The Care Coordination in the Community project, is supported by the CCTST Community Leaders Institute and led by Dr. Ernie Ciambarella (Queen City Physicians). The project involves five community based practices that are working together to develop sustainable and reliable processes for care coordination between the medical home and specialists at Cincinnati Children’s. Dr. Ciambarella convened a series of meetings with parents of children with medical complexity and practice team members to gather their insights to ensure the processes being developed met their needs. Tests of change have included using the Longitudinal Plan of Care (LPOC) in EPIC to support pre-visit planning and care coordination. The initial experience showed that the LPOC made the process more efficient for physicians, office staff, and parents. However, this test also raised awareness that the LPOC needs to be available in EPIC Link (in addition to EPIC) so non-physician staff members at community practices can access it.  Leadership at Cincinnati Children's responded to this need by enhancing EPIC Link. 

We produced a short video to share learnings from this project.  Click here to watch “Practical Tips about Pre-Visit Planning for Children with Medical Complexity.”

The sample care management plan featured in the video is available for download.

Community practices that refer patients to Cincinnati Children’s who would like to establish access to Epic Link can contact Stefanie Easley in Physician Services for additional information.  Phone:  636-6033 or Email: stefanie.easley@cchmc.org

The Improving Connections Between the Family, the Medical Home, and the School project is supported by a CCTST Community Health grant. Marilyn Crumpton, MD, MPH, (Cincinnati Health Department) is leading this effort in partnership with Cincinnati Public Schools, the Health Department, and Price Hill Health Center (PHHC) to improve the percentage of patients about whom there is bidirectional communication between PHHC and each school to ≥ 70%.

The Developing New Technologies to Help Manage ADHD is an NIH funded study, led by Bill Brinkman MD, MEd, MSc, that began in 2012 with the objective of enhancing an ADHD web portal with new features designed to promote positive interactions between parents and their child’s doctors and improve parent maintenance of their child’s medication. Enhancements were created in partnership with five Cincinnati-area pediatric practices with 18 pediatricians and 39 parents of children with ADHD. The iterative design process enabled physicians and parents to make important contributions from initial concept formation to usability testing of the new features. User feedback was critical for software programmers to improve the website. These new features are now being tested in 12 Columbus-area practices as part of the randomized controlled trial.

To determine whether participation in ECHO Autism will result in improved knowledge, clinical practice behavior and self-efficacy among Primary Care Providers (PCPs) in the areas of ASD screening and identification, and assessment and treatment of medical co-morbidities: Watch the Webinar.